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Addressing the Polypharmacy Challenge in Older People

The Polypharmacy Challenge Blog

Doing safety through care in the risky business of polypharmacy

Have you ever wondered what work goes into making up prescriptions? This paper, hot off the press, invites you behind the pharmacy counter, to witness the work pharmacy staff do to safely dispense medicines.

The number of prescription medicines is on the rise and this makes prescribing, dispensing and taking medicines ever more complex.
We show how pharmacy staff who are working within a fast-moving, high-risk environment achieve safe dispensing, through their focus on:
  • care for the technology
  • care for each other and
  • care for patients.
We join a number of authors who are bringing ‘care’ to the foreground to show what healthcare workers actually do, often within organisational cultures that reduce care to ‘tickboxes in an attempt to standardise this most unpredictable of human activities’.

What we did
Medicines safety is typically framed as avoidance of error; something that can be achieved through following formal policies and guidelines and paying attention to operational issues. Automation, robotics and technologies are seen as key players in the elimination of error despite limited research on how these innovations are taken up, used and adapted in practice.
We took a Safety-II approach to understand how safety really happens. Rather than focus only on how errors arise, a Safety-II approach focuses on learning from observing usual practice, where mostly practice occurs error-free.
We undertook ethnographic research in four community pharmacies to find out how pharmacy staff ‘do safety’ in the high-risk context of polypharmacy. We focused on the everyday routines and tasks staff engaged in when looking after patients who are prescribed numerous medicines.
We spent 140 hours observing pharmacy staff at work as they received prescriptions, organised medicines for dispensing, made up dosette boxes (pill organsiers), and communicated with clinicians in GP surgeries and hospitals. We also collected documents used by pharmacy staff such as checklists and standard operating procedures. We conducted 19 interviews with pharmacists, dispensers, technicians and counter staff.

What we found

‘Safety’ was a collective concern in all pharmacies. Staff used the term ‘safety’ when they told us how and why they did certain things: picking medicines from shelves in a particular order; asking patients for names and addresses; switching tasks regularly. Staff did not articulate what constitutes ‘safety’ in the course of their usual work, but in interviews they referred to safety as ‘the right drug, the right patient, the right time'.

Caring for the technology: We focused our observations on two key technologies: dosette boxes (either produced by hand or by a robot) and electronic prescriptions. We saw how staff devised new routines to get the best out of the technologies. The robot, for example, whilst speeding up dosette box production, did not negate the need for human input. If anything, the robot needed a lot of care. Staff created new tasks and routines to look after it and make sure it ran properly.

Caring for each other encompasses a number of practices to ensure safe working as a team. Members of staff were always alert, always listening and ready to take initiative. Staff were able to report errors without fear of negative consequences and we experienced a strong commitment to social cohesion.

Caring for patients: Safety emerged as a shared concern amongst pharmacy staff to care for patients. Even though staff may work behind the scenes, they talked of ‘knowing our dosette patients’. Technologies such as robots for dispensing and software enabling electronic prescriptions did not diminish relationships between pharmacy staff and patients. Staff often used imaginary scenarios (What ifs?) to demonstrate their performance of safety and their awareness of the high risk environment in which they worked.

What’s the link to polypharmacy?
Our study revealed an important paradox. Polypharmacy was plain to see from the vast quantities of medicines that came into the pharmacy and the many hours pharmacy staff spent making up dosette boxes and organising patients’ pills. Yet, polypharmacy itself was rarely discussed either between pharmacy staff or between pharmacists and GPs. This surprised us particularly as we became known as the ‘polypharmacy researchers’. When we tentatively asked about the pharmacists’ role in addressing polypharmacy, they regarded this as the responsibility of those who had prescribed the medicine: GPs and hospital doctors.

We would like to thank the pharmacy staff who generously gave their time and provided us with access to a vital world of work that mostly goes unseen.

You can read the full paper here (open access free to all)

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